The following procedures for grievances, coverage decisions and appeals must be followed by our health plan in identifying, tracking, resolving and reporting all activity related to a grievance, coverage decision and appeal. This is only a brief summary. Please refer to your Evidence of Coverage book for more details.

What to do if you have a problem or complaint

If you have a problem with the plan or with your services or payment there are processes available to help you communicate with the plan. These processes have been approved by Medicare. Each process has a set of rules, procedures, and deadlines that must be followed by the plan and by you.

You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with CareMore Health Plan or a Contracted Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information.

The following procedures for grievances, coverage determinations and appeals must be followed by our health plan in identifying, tracking, resolving and reporting all activity related to a grievance, coverage determination and appeal. This is only a brief summary. Please refer to your Evidence of Coverage book for more details.

Member Grievances

Who Can File a Grievance?

A grievance may be filed by any of the following:

You may file a grievance.

Someone else may file the grievance for you on your behalf.

Appointing a Representative

You may appoint an individual to act as your representative to file the grievance for you by following the steps below:

Provide our health plan with your name, your Medicare number and a statement which appoints an individual as your representative. (Note: You may appoint a physician or a Provider.) For example: "I [your name] appoint [name of representative] to act as my representative in filing a grievance regarding the ____________."

Provide your name, address and phone number and that of your representative, if applicable.

You must sign and date the statement.

Your representative must also sign and date this statement.

You must include this signed statement with your grievance.

You can get an Appointment of Representative form on the Medicare website by clicking the link below, or you may contact Member Services and ask that one be sent to you.

A grievance is a type of complaint that does not involve payment, denial or discontinuation of services by CareMore Health Plan or a Contracting Medical Provider. For example, you would file a grievance if: you have a problem with things such as the quality of your care during a hospital stay; you feel you are being encouraged to leave your plan; waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room; waiting too long for prescriptions to be filled; the way your doctors, network pharmacists or others behave; not being able to reach someone by phone or obtain the information you need; or lack of cleanliness or the condition of the doctor's office.

When Can a Grievance Be Filed?

You may file a grievance within sixty (60) calendar days of the date of the circumstance giving rise to the grievance. There is no filing limit for complaints concerning quality of care.

Expedited Grievance

You have the right to request a fast review or expedited grievance if you disagree with CareMore Health Plan's decision to invoke an extension on your request for an organization determination or reconsideration, or CareMore Health Plan's decision to process your expedited request as a standard request. In such cases, CareMore Health Plan will acknowledge your grievance within twenty-four (24) hours of receipt.

Where Can a Grievance Be Filed?

A grievance may be filed in writing directly to us or contacting our Member Services Department at our toll free number 1-888-816-2790, between 8:00 a.m. - 8:00 p.m., 7 days a week from October 1 to February 14, and 8:00 a.m. - 8:00 p.m., Monday to Friday from February 15 to September 30, TTY/TDD users should call 711.You may also contact our Member Services Department and request the facsimile number for Appeals and Grievances. You also are able to mail your Grievance to our Appeals and Grievances Department at:

Coverage Decisions

What Is a Coverage Decision for Medicare Part C (Not Part D drugs)?

A coverage decision is an initial decision we make about your benefits and coverage or about the amount we will pay for your medical services, items, or Part B drugs. We also call this an Organization Determination.

Who Can Request an Organization Determination?

You or your representative may request an Organization Determination.

Your doctor or other health care provider can request an organization determination for you on your behalf. Your doctor does not need to complete the Appointment of Representative form for coverage decision requests.

How do I request an Organization Determination?

You, your representative, or your doctor can request an Organization Determination by writing directly to us or contacting our Member Services Department at our toll free number 1-888-816-2790, between 8:00 a.m. - 8:00 p.m., 7 days a week from October 1 to February 14, and 8:00 a.m. - 8:00 p.m., Monday to Friday from February 15 to September 30, TTY/TDD users should call 711. You may also contact our Member Services Department and request the facsimile number for Appeals and Grievances. You also are able to mail your request to our Member Services Department at:

Our plan has 14 calendar days from the date it gets your request to notify you of its decision. However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will notify you by letter.

If you need a response faster because of your health, you should ask us to make a "fast organization determination." If we approve the request, we will notify you of our decision within 72 hours. However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will notify you by letter.

Here are the rules for asking for a fast organization determination:

You are asking about care you have not yet received. (You cannot get a fast organization determination if your request is about care you have already received.)

The standard timeframe could cause serious harm to your health, or hurt your ability to function.

If your doctor says that you need a fast organization determination, we will automatically give you one.

If you ask for a fast organization determination, without your doctor's support, we will decide if you get a fast organization determination.

If we decide that your health does not meet the requirements for a fast coverage decision, we will send you a letter. We will also use the standard 14 calendar day deadline instead.

Important Things to Know About your request

The plan will send you a letter telling you whether or not we approved coverage. Our plan can say "yes" or "no" to your request

If we approve your request, you will be authorized to get the service within 14 calendar days (for a standard organization determination) or 72 hours (for a fast organization determination) from the time you asked us.

If we say no to your request, you can ask for a review of our decision by making an appeal. Making an appeal means asking us to review our decision to deny coverage.

What Is a Coverage Decision for Outpatient Drugs (Part D drugs)?

A coverage decision is an initial decision made by our plan (not the pharmacy) about your prescription drug benefits, including whether a particular drug is covered, whether you have met all the requirements for getting a requested drug, how much you're required to pay for a drug, and whether to make an exception to a plan rule when you request it. We also call this a Coverage Determination.

What Is an Exception?

If a drug is not covered on our plan, you can ask the plan to make an "exception." An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision. When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request.

When Can a Coverage Determination/Exception Be Requested?

A coverage determination may be requested for any of the following:

1. Covering a Part D drug for you that is not on our plan's List of Covered Drugs (Formulary).

You may ask our plan for an exception if you or your prescriber (your doctor or other health
care provider who is legally allowed to write prescriptions) believes you need a drug that isn't on your drug plan's list of covered drugs.

You may ask for an exception if your network pharmacy can't fill a prescription as written.

2. Removing a restriction on the plan's coverage for a covered drug.

You may ask for an exception if you or your prescriber believe that a coverage rule (such as a
prior authorization) should be waived.

3. Changing coverage of a drug to a lower cost-sharing tier. (Tier Exception)

You may ask for an exception if you think you should pay less for a higher tier drug because
you or your prescriber believe you can't take any of the lower tier drugs for the same condition.

4. Request for payment.

You may ask us to pay for a prescription that you already paid cash for.

Who Can Request a Coverage Determination/Exception?

A coverage determination may be requested by any of the following:

You or your representative may request a coverage determination.

Your prescriber (your doctor or other health care provider who is legally allowed to write
prescriptions) can request a coverage determination for you on your behalf. Your doctor does not need to complete the Appointment of Representative form for coverage decision requests.

Important Things to Know About Asking for Exceptions

Your doctor or other prescriber must give us a written statement that explains the medical reasons for requesting an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception.

Our plan can say "yes" or "no" to your request

If we approve your request for an exception, our approval usually is valid until the end of the plan year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.

If we say no to your request for an exception, you can ask for a review of our decision by making an appeal. Making an appeal means asking us to review our decision to deny coverage.

If your health requires a quick response, you must ask us to make a "fast coverage determination".

Where Can an Exception Be Filed?

You, your representative, or your prescriber can request an exception or expedited coverage determination by writing directly to us or contacting our Member Services Department at our toll free number 1-888-816-2790, between 8:00 a.m. - 8:00 p.m., 7 days a week from October 1 to February 14, and 8:00 a.m. - 8:00 p.m., Monday to Friday from February 15 to September 30, TTY/TDD users should call 711. You may also contact our Member Services Department and request the facsimile number for Appeals and Grievances.

Our plan has 72 hours (for a standard request) or 24 hours (for an expedited request) from the date it gets your request to notify you of its decision.

Member Appeals

Who Can File an Appeal?

An appeal may be filed by any of the following:

You may file an appeal.

Someone else may file the appeal for you on your behalf.

Appointing a Representative

You may appoint an individual to act as your representative to file the appeal for you by following the steps below:

Provide our health plan with your name, your Medicare number and a statement which appoints an individual as your representative. (Note: You may appoint a physician or a Provider.) For example: "I [your name] appoint [name of representative] to act as my representative in requesting an appeal from CareMore Health Plan and/or CMS regarding the denial or discontinuation of medical services."

Provide your name, address and phone number and that of your representative, if applicable.

You must sign and date the statement.

Your representative must also sign and date this statement.

You must include this signed statement with your appeal. Complaints and appeals may be filed over the phone or in writing.

You can get an Appointment of Representative form on the Medicare website by clicking the link below, or you may contact Member Services and ask that one be sent to you.

An appeal is a type of complaint you make when you want us to review a decision that was made regarding coverage of a service, the amount we paid for a service, will pay for a service or the amount you must pay for a service.

For example, you may file an appeal for any of the following reasons:

CareMore Health Plan refuses to cover or pay for services or a drug you think CareMore Health plan should cover.

CareMore Health Plan or one of the Contracting Medical Providers refuses to give you a service or a drug you think should be covered.

CareMore Health Plan or one of the Contracting Medical Providers reduces or cuts back on services you have been receiving.

If you think that CareMore Health Plan is stopping your coverage too soon.

When Can an Appeal Be Filed?

You may file an appeal within sixty (60) calendar days of the date of the notice of the initial organization determination. Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day timeframe.

Where Can an Appeal Be Filed?

An appeal may be filed in writing directly to us or contacting our Member Services Department at our toll free number 1-888-816-2790, between 8:00 a.m. - 8:00 p.m., 7 days a week from October 1 to February 14, and 8:00 a.m. - 8:00 p.m., Monday to Friday from February 15 to September 30, TTY/TDD users should call 711. You may also contact our Member Services Department and request the facsimile number for Appeals and Grievances. You also are able to mail your Appeal to our Appeals and Grievances Department at:

You may use the appeal procedure when you want a reconsideration of a decision (organization determination or coverage determination) that was made regarding a service or the amount of payment CareMore Health Plan paid for a medical service or a drug.

What Do I Include With My Appeal?

You should include: your name, address, member ID number, reasons for appealing, and any evidence you wish to attach. You may send in supporting medical records, doctors' letters, or other information that explains why your plan should provide the service or a drug. Call your doctor if you need this information to help you with your appeal. You may send in this information or present this information in person if you wish.

What Happens Next?

If you appeal, we will review the decision. If any of the services you requested are still denied after our review, you may have further appeal rights. You will be notified of those appeal rights if this happens.

Fast Decisions/Expedited Appeals

You have the right to request and receive expedited decisions affecting your medical treatment in "Time-Sensitive" situations. A Time-Sensitive situation is a situation where waiting for a decision to be made within the timeframe of the standard decision-making process could seriously jeopardize:

Your life or health, or

Your ability to regain maximum function.

Medicare Part C Appeals

Our plan has 30 calendar days (for a standard request) or 72 hours (for an expedited request) from the date it gets your request to notify you of its decision. However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will notify you by letter.

Part D Appeals

Our plan has 7 calendar days (for a standard request) or 72 hours (for an expedited request) from the date it gets your request to notify you of its decision.

If CareMore Health Plan or your Primary Care Physician decides, based on medical criteria that your situation is Time-Sensitive or if any physician calls or writes in support of your request for an expedited review, CareMore Health Plan or your Primary Care Physician will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours after receiving the request.

CareMore Health Plan is an HMO/HMO SNP plan with a Medicare contract.
Enrollment in CareMore Health Plan depends on contract renewal.
You can provide feedback directly to Medicare through their online Complaint Form